Tips of proximal quadriceps stretch for strong stiffness with lower back pain

Ref: https://www.bicycling.com/

Quadriceps muscle is bi - articular joint muscle of hip and knee. Its function includes straight knee joint and flex hip joint that stretch the lower back, gluteal and hamstring. Normally, tightness of the quadriceps develops knee bending limitation that when bending the knee, the patient will feel tension at the muscle belly.

My physiotherapy experience, I have seen tightness of the proximal quadriceps in IT band syndrome, upper gluteal pain, and low back pain sometimes. If I take care of these cases, I will add on the proximal quadriceps assessment for more information. Mention to anatomy, this muscle can irritate pelvic posture due to the origin of attachment on a part of the pelvic where is AIIS. 

Quadriceps origin (red mark)
(Ref: https://compedgept.com/blog/)

Sometimes, I have found tightness of the proximal quadriceps following tightness of TFL. Perhaps, their origins are very near and they are located like a neighborhood. Sometimes, I have found only one of them gets tight. However, I would like to recommend stretching the proximal quadriceps if it demonstrated tightness. It can help to release rear side pain and improve posture. 

Strong stiffness of proximal quadriceps that cannot straight hip joint from flexion position.

Previously, I presented the way to stretch quadriceps. I have seen some patients had very strong stiffness of that tissue that would be the threat of recovery. Some of them have done the stretching difficulty. The patients alway compensate i.e. arch lower back or cannot upright hip and torso. 

Arching at lower back to compensate

I found one tips of proximal quadriceps stretch for strong stiffness as this VIDEO

Exercise #1: Half kneeling with toe stand stretch: the target leg is on the knee with set ankle at neutral. Lean back and pelvic backward slightly without arching the lower back. We need hip joint to be neutral or extension.

Case sample 1

Case triathlon athlete who has got both lateral groin pain after cycling training. The patient denied low back pain and gluteal pain. The muscle length assessment found tightness of both proximal quadriceps and slight tightness of TFL. This case did not has gluteus medius weakness that did not persuade me to think of IT band syndrome. One of my treatment processes was isometric contraction of quadriceps before proximal quadriceps stretching as demonstrated VIDEO. 

Cycling posture demonstrates prolonged hip flexion with prolonged gluteal and lower back stretch
(Ref: https://www.giant-bicycles.com/)

Case sample 2

Case swimmer who has got one side of the upper gluteal pain that was worse pain by crawl stroke and butterfly stroke. The patient did not has low back pain and knee pain. Gluteal muscles got pain from pressing and weakness which was gluteus maximus. The gluteus medius was a normal strength that  did not persuade me to think of IT band syndrome. QL and back extensor muscle were not spasms. I almost concluded only inflammation of gluteus maximus muscle, but I have seen slight hip flexion in supine lying. Additionally, the quadriceps muscle mass looked massive that illustrated the groove between ASIS and quadriceps belly.

Middle posture demonstrate quadriceps look like massive and groove between ASIS and quadriceps. Right posture demonstrate neutral posture that not demonstrate groove between ASIS and quadriceps.
(Ref: https://www.kateskinnerpt.com/posture-and-positioning) 

            This groove was only on the pain side and not on the other one. I did more evaluation for quadriceps muscle length, then it showed tightness of the proximal quadriceps. One of my treatment processes was stretching proximal quadriceps and gluteus maximus facilitation. I gave a home program assignment for stretching as demonstrated VIDEO and exercise gluteus maximus. 

Case sample 3

Case of a computer office worker who has got one side of upper gluteal pain and neck pain with radiation to the lateral thigh and tibia from forward reaching to put something on the shelf 2 months ago. The patient was treated by medicine, physiotherapy modalities, and stretching of the gluteus and hamstring. Firstly, I considered about piriformis syndrome. The job characteristic is prolonged sitting at the working desk. The standing posture showed a torso shift forward. There was severe pain and hypersensitivity that felt pain at the gluteus maximus, gluteus medius, TFL, and quadriceps. Torso forward bending was limited by pain with a very narrow range. Torso backward bending was limited by worse pain and radiated to the lateral foot. It was not only pain but also numbness on some range of motion that made me think about nerve irritation.

One sample of stand and reach function in normal life living that can stress to lower back and gluteal
(Ref: https://depositphotos.com/)

            I started treatment with a gentle massage on my iliopsoas and quadriceps because firstly my aim was improve posture. It was a good response that pain intensity was decreased significantly. Then I started stretching iliopsoas and proximal quadriceps gradually where pain and numbness free. After the hip extension range increased, I started gluteus maximus facilitation to the hip stability function. Finally, the pain intensity decreased 70 - 80% with improved standing posture. The torso range of motion and all tenderness of gluteal muscle were improved. I gave a home program assignment for stretching as demonstrated VIDEO and exercise gluteus maximus. Moreover, the patients was recommended not to be prolonged sitting because proximal quadriceps may be tight together with prolonged stretch gluteal region. I concluded this case was upper gluteal strain with proximal quadriceps spasm.  

Prone hip extension exercise for strengthen gluteus maximus
(Ref: https://www.saintlukeskc.org/)

 

The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following a demonstrated VIDEO. 

9 options to stretch posterior fibers of hip adductor with physiotherapist

 

Sketing on ice e.g. race and hockey is potential to develop adductor magnus tight or injury
(Ref: https://www.sportsinjurybulletin.com/adductor-magnus-tales-of-tightness/)

All hip adductors work at the hip joint to adduct and forward bend but only one muscle provides flexion and extension function. This muscle is an adductor magnus that has anterior fibers to assist in flexion, while posterior fibers to assist in extension. 

“The way to stretch extensor muscles needs to reverse the direction that flexes the hip joint”.

9 options to stretch posterior fibers of hip adductor

Exercise #1: Sumo (Horse stance): Both leg toe out, then squat, bend torso forward for more stretch.

Exercise #2: Lizard pose: Target leg is fore - leg and outerward to hand

Exercise #3: Butterfly pose: Place both plantar together, then keep knee close to floor as postible as you can. Bend torso forward for more stretch.

Exercise #4: Long sitting hip abduction: Bend torso forward that touch the floor away as far as possible for more stretch. Keep knee straight.

Exercise #5: Kneeling lateral lunge

Exercise #6: Prone frog

Exercise #7: Supine lizard

Exercise #8: Happy baby

Exercise #9: Supine wall hip abduction

The adductor magnus is the largest of the hip adductors and the third largest among all of the muscles in the lower limb, is only smaller than the quadriceps femoris and the gluteus maximus.  It is a fan - shaped muscle and located in the deepest of medial thigh muscles. It is rarely injured, opposite, the adductor longus is the most commonly injured muscle.   

Fan - shape 
(Ref: https://www.istockphoto.com/)

The adductor magnus derived tendon at inferior pubic rami, ramus of ischium (anterior fiber), and ischial tuberosity (posterior fibers). Because of this proximity to the ischial tuberosity, some even consider the ischial portion of the adductor magnus to be part of the hamstring muscle group.  Muscle fibers of adductor magnus are closely related to the origin of semimembranosus and the fiber orientation of adductor magnus is similar with hamstring, so it is intimately related to the proximal hamstring musculature. The insertion is at medial to gluteal tuberosity, middle of linea aspera, medial supracondylar line, and adductor tubercle of medial condyle of femur. Muscle fibers of adductor magnus are closely related to the origin of semimembranosus and the fiber orientation of adductor magnus is similar with hamstring

The adductor magnus derived tendon at inferior pubic rami, ramus of ischium (anterior fiber) which represented by blue and ischial tuberosity (posterior fibers) which represented by red.
(Ref: https://www.researchgate.net/publication/283718715_The_adductor_magnus_mini-hamstring_MRI_appearance_and_potential_pitfalls/download)

            According to anatomically, it is the most complex adductor muscle, which plays a role in the flexion and extension movements of the hip joint and stabilizes the posteromedial compartment of hip joint. 

    Its attachment not only complicates only the proximal part but also distal part that the adductor magnus has been divided into a “adductor” part and “hamstrings” part. The pubofemoral muscle fibers/adductor parts are directed horizontally that insert along the plane between the greater trochanter and linea aspera. The ischiofemoral fibers/hamstring part have vertical and lateral fibers that insert onto the linea aspera and adductor tubercle. The adductor tubercle is a bony protuberance, situated just cranial to the medial epicondyle of femur and is the caudal most point of the medial supracondylar line serving as the insertion point of the ischiofemoral portion of the adductor magnus muscle (hamstring).

Hip adductor magnus:
pubofemoral muscle fibers/adductor parts (purple), ischiofemoral fibers/hamstring part (red)
(Ref: https://www.researchgate.net/publication/283718715_The_adductor_magnus_mini-hamstring_MRI_appearance_and_potential_pitfalls/download)

 

The adductor magnus musculotendinous junction occurs approximately at the level of the junction of the middle and distal thirds of the femur. The distal tendon has a long course to its insertion onto the adductor tubercle. There are many ligamentous and tendinous attachments in close proximity to the adductor magnus insertion onto the adductor tubercle; e.g. the medial patellofemoral ligament (MPFL), the posterior oblique ligament originates slightly posteroinferiorly to the AT and is directed caudally, blending distally with the semimembranosus tendon, the gastrocnemius tubercle is located distal and posterior to adductor tubercle that giving attachment to the medial head of gastrocnemius, the medial collateral ligament (MCL). 

Adductor tubercle is superior to femur medial epicondyle
where adductor magnus and many soft tissues attach.
(Ref: Huleatt J., Geeslin A., LaPrade R. (2014) Special Considerations for Multiple-Ligament Knee Injuries. In: Doral M., Karlsson J. (eds) Sports Injuries. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-36801-1_112-2)

Electromyography (EMG) studies have investigated the gluteus maximus (Gmax), hamstring and the adductor magnus muscles as the primary hip extensors during prone hip extension. The results of this study support the hypothesis that during prone hip extension exercise, the adductor magnus would have statistically similar activity with the Gmax, medial hamstring, and lateral hamstring. Therefore, the adductor magnus can work in hip extension as same as Gmax and hamstring muscles.

    Referring to its function, I gave massage and stretching on the hamstring and adductor magnus in one patient with a flat back. Due to, shortening of hamstring and abdominal muscle involve flat back posture. The outcome showed an increase of lumbar lordosis that satisfied me. However, I will observe this method in the future carefully. 

Adductor magnus is medial hamstring neighbor 
(Ref: https://loveyogaanatomy.com/sitbone-pain-from-yoga-asana/)

    To prevent hip adductor disorders needs to strengthen this muscle especially who are prolonged sitting worker, and stretch them with the same as the other muscles: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

Reference: 

http://physiosports.com.au/wp-content/uploads/2015/07/takizawa-2012-why-add-magnus-muscle-is-large.pdf

https://www.researchgate.net/publication/290210457_Anatomy_of_the_Adductor_Magnus_Origin_Implications_for_Proximal_Hamstring_Injuries

https://www.thieme-connect.com/products/ejournals/pdf/10.4103/ijri.IJRI_523_19.pdf 

https://www.researchgate.net/publication/324118428_Comparison_of_hip_extensor_muscle_activity_including_the_adductor_magnus_during_three_prone_hip_extension_exercises 

https://www.jospt.org/doi/epdf/10.2519/jospt.2010.3025 

https://www.researchgate.net/publication/51823221_A_review_of_the_anatomy_of_the_hip_abductor_muscles_gluteus_medius_gluteus_minimus_and_tensor_fascia_lata 

https://core.ac.uk/download/pdf/270251533.pdf 

https://aassjournal.com/article-1-1057-en.pdf 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4714133/pdf/10.1177_2325967115625055.pdf 

https://www.researchgate.net/publication/317366152_Assessment_and_management_of_adductor_strain 

Physiotherapy with 7 options to stretch hip adductor anterior fibers

Hip adductor strain groin pain in soccer
(Ref: https://www.limpinleapoutphysiotherapy.com.au/blog1/groin-pain-in-soccer-players)

There are several musculoskeletal disorders involve groin pain, for example, osteitis pubis, Insertional adductor and rectus abdominis tendinopathy, Apophyseal avulsion fractures, Femoroacetabular impingement (FAI) syndrome that hip adductors strain is one of the most common injuries in athletes.  

Normally, groin injuries make up 2% – 5% of all sport ‑ induced injuries, of which adductor strain is the usual musculoskeletal etiology of the pain. The most common sports that put athletes at risk for adductor strains are football, soccer, hockey, basketball, tennis, figure skating, baseball, horseback riding, karate, softball, and cricket. 

Hip adductors strain have risk multifactorial; include, different forms of sports, high level of play, age and core stability, previous hip adductor injury, hip adductor - to - abductor strength imbalance, and adductor tightness.

Anterior thigh view with hip adductor are in medial side
(Ref: https://www.britannica.com/science/quadriceps-femoris-muscle)

Hip adductor muscles shortening affected pelvic tilt posture both of anterior - posterior plane and lateral plane. The position is one of lateral pelvic tilt, with the pelvis so high on the side of contracture in standing. Legs alignment would be changed because of this deformity. Tightness  of  secondary hip flexors, such as adductor brevis, gracilis, and anterior fibers of the gluteus minimus,  would, in  theory, contribute to an excessive anterior pelvic tilt and exaggerated lumbar lordosis.

Some hip adductor fibers which arise from the anterior surface of pubic will assist to flex the hip joint. By the way, all of them contract to adduct and internally rotate the hip joint.

7 ways to stretch hip adductors 

Exercise #1: stand hip abduction with lateral pelvic shift stretch: spread both legs 2 - 3 times shoulder wide. Then, tilt up the opposite pelvic side of target leg laterally.

Exercise #2: stand lateral lunge stretch: spread both legs 2 - 3 times shoulder wide. Then, bend supported leg like lateral lunge squat to stretch target leg which is opposite side.

Exercise #3: supine frog stretch: For standard stretching, keep both feet together during stretching. For advance stretching, separate both feet away.

Exercise #4: modified lion stretch: keep both feet together during stretching. Control hips in extension postition, not back extension.

Exercise #5: figure of 4 stretch: for more stretch, we needs move knee close to floor as far as possible.

Exercise #6: Half kneeling lateral shift stretch: it is used for stretching leg which is kneeling.

Exercise #7: stand lateral lunge with hip extension stretch: spread both legs 2 - 3 times shoulder wide with hands are on the wall. Then, target leg turn to toe out. And supported leg step forward to prepare squating. Supported leg squat with shift weight forwatd and laterally for position target leg in hip extension, hip external rotation, hip abduction.

A common mechanism of the injury is sudden change of direction or violent external rotation with abduction at hip joint while the foot is planted on ground with eccentric contraction that my patients and I underwent before. The most common hip adductor strain is hip adductor longus.

Once, I got a hip adductor strain during soccer games. It happened very fast, I stepped my right leg to the ball with poor leg position because of fatigue. Then, I stepped my left leg to the right to keep balance and play on. Suddenly, my torso twisted with a "pop sound" at my left hip. I fell on the ground and was carried afterward. I had stopped all my exercise for 4 months. 

The five primary hip adductors include the pectineus, gracilis, adductor longus, adductor  brevis, and adductor magnus (both anterior and posterior heads). Secondary adductors include the biceps femoris (long head), the gluteus maximus (especially the posterior fibers), quadratus femoris, and obturator externus. 

The muscles testing and function textbook which was written by Kendall, stated primary hip adductors anatomy that: 

The pectineus arise at the surface of superior ramus of the pubis ventral to pecten between ilioppectineal eminence and pubic tubercle, and inserted at pectineal line of femur distally. 

Pectineus muscle
(Ref: https://michael-loehr.com/muscles-of-the-lower-limb/)

The adductor magnus derived tendon at inferior pubic rami, ramus of ischium (anterior fiber), and ischial tuberosity (posterior fibers), then had insertion at medial to gluteal tuberosity, middle of linea aspera, medial supracondylar line, and adductor tubercle of medial condyle of femur.

Hip adductor magnus
(Ref: https://michael-loehr.com/muscles-of-the-lower-limb/)

The origin of adductor brevis was at the outer surface of inferior ramus of pubis, and had distal attachment at distal two thirds of pectineal line, and proximal half of medial lip of linea aspera.

Hip adductor brevis
(Ref: https://michael-loehr.com/muscles-of-the-lower-limb/)

The adductor longus had origin not far from its friends which is the anterior surface of pubis at junction of crest and symphysis, and had insertion at the middle one thirds of medial lip of linea aspera. 

Hip adductor longus
(Ref: https://michael-loehr.com/muscles-of-the-lower-limb/)

         
        The gracilis started at the inferior half of symphysis pubis and medial margin of inferior ramus of pubic bone, then passed on medial side of femur to the medial surface of body of tibia, distal to condyle, proximal to insertion of semitendinosus, and lateral to insertion of sartorius. It is only one muscle which is two joint muscle of hip adductor group.

Gracilis
(Ref: https://michael-loehr.com/muscles-of-the-lower-limb/)

All of the above provide adduct hip joints, majorly. The pectineus, adductor brevis, and adductor longus flex the hip joint. The anterior fibers of the adductor magnus which arise from the rami of the pubis and ischium may assist in flexion, while the posterior fibers that arise from the ischial tuberosity may assist in extension. The gracilis, in addition to adducting the hip joint, flexes and medially rotates the knee joint. In addition to hip adduction, these muscles help stabilize the hip and lower limbs during the standing phase of the gait. Therefore, their function consists of hip adduction, hip flexion, hip internal rotation, and some fibers of them assist hip extension.      

      

           To prevent hip adductor strain needs to strengthen the hip adductor in eccentric function especially in standing or step in, and stretch them with the same as the other muscles: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO. 

Reference: 

https://www.jospt.org/doi/epdf/10.2519/jospt.2010.3025 

https://www.researchgate.net/publication/51823221_A_review_of_the_anatomy_of_the_hip_abductor_muscles_gluteus_medius_gluteus_minimus_and_tensor_fascia_lata 

https://core.ac.uk/download/pdf/270251533.pdf 

https://aassjournal.com/article-1-1057-en.pdf 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4714133/pdf/10.1177_2325967115625055.pdf 

https://www.researchgate.net/publication/317366152_Assessment_and_management_of_adductor_strain 

Physiotherapy with 5 options of the sartorius stretching exercise which we always neglect.

Ref: https://www.yoganatomy.com/sartorius-muscle/

 

The incidence of upper thigh injuries include the adductor (23%), hamstring (12– 37%) or quadriceps (19%), whilst  sartorius muscle injuries occur in 31–46%. The pathogenesis of muscle injuries is divided into extrinsic and intrinsic injuries. 

Intrinsic injuries are caused by contraction or elongation of the muscle that mainly involve type II muscle fibers which rapidly contract. It extends between two joints, contracts eccentrically and has a fusiform muscle fiber arrangement, leading to destruction of the internal muscle fiber. There are 3 grade injuries categories based on the extent of the lesion: grade I involves a few muscle fibers within a bundle; grade 2 involves up to three/fourths of the affected muscle portion; and grade 3 involves more than three/fourths, and the lesion may then involve the entire muscle belly.

Extrinsic injuries include factors such as contusions and penetrating wounds that can involve all types of muscle fibers.

5 options of the sartorius stretching exercise

Exercise #1: Sartorius stand wall stretch: Hands are on the wall for maintain balance. Step target leg backward, then adduct as behind front leg, then medial rotation as toe in, then move pelvic forward.

Exercise #2: Sartorius stand leg curl stretch: Bend target knee with hand support, then situate target shin laterally, then extend hip joint without arch lower back.

Exercise #3: Sartorius semi side lying stretch: Lying on the side to the opposite side of the target leg that makes the target leg is behind. Target leg was pushed by hand forward. Then rotate the torso to mid line again. 

Exercise #4: Sartorius side lying stretch: Shin should be lateral to thigh in the end of pose setting.

Exercise #5: Sartorius supine stretch: For beginners, you should supine on the elbow. For advances, you can lie on the back. 

I hardly have seen patients with sartorius injury. Most of my rare cases always complained e.g. proximal anteromedial tibia pain which was pes anserine, VMO pain, fore - thigh pain, proximal lateral groin pain, MCL pain. I had to evaluate carefully to clear the root curse and site of injury. 

One sample case, He was overlapped by one soccer player on the leg  while his knee was bending. He went to see a doctor and he was diagnosed with a knee tendon or ligament injury. A few days later, he came and saw me at physio clinic for more investigation and needed some advice. After subjective examination and physical evaluation, they indicated sartorius tendon more than MCL. To answer the question was how long should he rest? I investigated him by sonography, then the injured site demonstrated grade I. So, we can say his injury was the result of an extrinsic factor.

One author found that injuries of the sartorius muscle most often occur in the area of proximal and distal attachment. At the proximal part, common activity of the sartorius muscle and TFL can cause ASIS avulsion that may be observed. At distal insertion, frequently repetitive movements leading to micro injuries and tissue loads in this area are met. In the result of this, inflammations of bursa anserina, tendon strains and rupture may take place in what was pes anserinus. Such injuries happen to: i.a. athletes, runners, jumpers and football players.

Pes anserine bursitis site
(Ref: http://therundoctor.com/pes-anserine-bursitis/)

The sartorius muscle is the longest muscle in humans. Its name derives from a Latin word “sartor” that did mean “a tailor”. 

The sartorius muscle is situated superficially, moreover, it is distinguished by an original shape and a course. It has got a transverse section in the shape of a triangle with the base upturned. The proximal tendon of the sartorius arises from the anterior superior iliac spine. The muscle belly is like an S-shaped running obliquely across the upper anterior third of the thigh in an inferomedial direction and tape twists around the anterior to the medial surface of the thigh. The belly of the sartorius constitutes the anterior wall of the adductor canal. Then the belly turns slantwise forward at the medial epicondyle of femur which together with quadriceps — its medial head — serves as a “trochlea” for the sartorius muscle. Its distal insertion onto the anteromedial proximal tibia as a flat divergent tendon creating in its further section superficial part of the pes anserinus. 

Sartorius muscle
(Ref: https://www.pinterest.com/)

The sartorius muscle is a biarticular muscle or two joint muscles. It is the only muscle of the thigh which bends both hip joint and knee joint. The sartorius is mainly a flexor of the hip  with the accessory function of lateral rotation and abduction of the hip as well as flexion and medial rotation of the knee. So, there are 4 directions of muscle activity including hip flexion, hip abduction, hip lateral rotation, and tibia medial rotation with knee flexion which action is like a cross single leg chair sitting. 

Ref: https://quizlet.com/

Moreover, it has worked as a hip and knee flexor starter that initializes the movement of flexion in both joints from the phase of full extension. Although the sartorius muscle is a weak external rotator and a weak abductor of the hip joint, it plays an important part in stabilization of the pelvis, especially in women. 

In my physiotherapy experience, stretching this muscle was not as easy as many muscles because it did not provide obvious tension. However, the principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hole at the point for 30 seconds of 3 - 5 reputations as demonstrated VIDEO.

Reference: 

https://www.researchgate.net/publication/266027219_Anatomy_of_sartorius_muscle 

https://theultrasoundjournal.springeropen.com/track/pdf/10.1186/s13089-019-0132-9.pdf 

https://www.orthopaedicmedicineonline.com/downloads/pdf/B9780702031458000843_web.pdf